Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational Study of Employment Outcomes

Accepted Manuscript Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational Study of Employment Outcomes Lisa Ottomanelli, PhD, Lance L. Goetz, MD, Scott D. Barnett, PhD, Eni Njoh, MPH, Thomas M. Dixon, PhD, ABPP, Sally Ann Holmes, MD, James LePage, PhD, Doug Ota, MD, Sunil Sabharwal, MD, Kevin T. White, MD PII:

S0003-9993(17)30012-6

DOI:

10.1016/j.apmr.2016.12.010

Reference:

YAPMR 56769

To appear in:

ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 6 May 2016 Revised Date:

7 December 2016

Accepted Date: 10 December 2016

Please cite this article as: Ottomanelli L, Goetz LL, Barnett SD, Njoh E, Dixon TM, Holmes SA, LePage J, Ota D, Sabharwal S, White KT, Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational Study of Employment Outcomes, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2017), doi: 10.1016/j.apmr.2016.12.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT APMR D-16-00556R2 Running head: IPS in SCI

Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational

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Study of Employment Outcomes

Lisa Ottomanelli, PhD1,2 ; Lance L. Goetz, MD3,4; Scott D. Barnett, PhD1; Eni Njoh,

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MPH1; Thomas M. Dixon, PhD, ABPP5; Sally Ann Holmes, MD6; James LePage,

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PhD7,8; Doug Ota, MD9,10; Sunil Sabharwal, MD11,12; Kevin T. White, MD1

1. VA HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans Hospital, Tampa, FL

2. Department of Rehabilitation and Mental Health Counseling, University of South Florida,

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Tampa, FL

3. Hunter Holmes McGuire VA Medical Center, Richmond, VA 4. Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University,

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Richmond, VA

5. Louis Stokes Cleveland Department of Veterans Affairs Medical Center

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6. Michael E. DeBakey VAMC, Houston, TX 7. VA North Texas Healthcare System, Dallas, TX 8. Department of Psychiatry, University of Texas Southwestern Medical School 9. VA Palo Alto Health Care System, Palo Alto, CA 10. Division of Physical Medicine and Rehabilitation, Stanford University, Stanford CA. 11. VA Boston Health Care System, Boston, MA 12. Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA

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Acknowledgement of Financial Support: This material is based on work supported by

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the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Rehabilitation Research and Development Service, Project #O7824R.

Conflict of Interest and Disclaimer: The authors have no conflicts of interests.

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Contents of this article do not represent the views of the Department of Veterans Affairs

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or the United States Government.

Address correspondence to: Lisa Ottomanelli, PhD, James A. Haley Veterans’ Hospital, 8900 Grand Oak Circle, Tampa, FL 33637. Telephone, (813) 558-3917.

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[email protected]. Reprints are not available.

Clinical Trial Number: NCT01141647

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Acknowledgements: We wish to acknowledge the following site investigators: Herb Ames, PhD; Maggie Budd, PhD, ABPP; Kirsten Fisher, MD; Anthony Kerrigan, PhD; B.

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Jenny Kiratli, PhD; Melissa Amick, PhD; Scott McDonald, PhD; Fides Pacheco, MD; Mary Ann Richmond, MD; Catherine Wilson PsyD, ABPP; and the Compensated Work Therapy program managers and study team members who supported this work. We acknowledge the dedicated efforts of fidelity monitors, Richard Toscano, MEd, and Charles McGeough, MSW, the National SE Clinical Coordinator, and Virginia “Jennie” Keleher, MSW, along with our study executive committee and staff at the HSR&D

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CINDRR. We appreciate the editorial assistance of Lynn Dirk, MAMC, in the

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preparation of this manuscript.

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Title:

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Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational

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Study of Employment Outcomes.

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Abstract

6 Objective

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To determine the effects of a 24-month program of Individual Placement and Support

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(IPS) supported employment (SE) on employment outcomes for veterans with spinal cord

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injury (SCI).

11 Design

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Longitudinal, observational multi-site study of a single arm, non-randomized cohort.

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Setting

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SCI centers in the Veterans Health Administration (VHA) (n=7).

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17 Participants

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Veterans with SCI (n=213) enrolled during an episode of either inpatient hospital care

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(24.4%) or outpatient care (75.6%). More than half the sample (59.2%) had a history of

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traumatic brain injury (TBI).

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Intervention(s)

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IPS SE for 24 months.

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Main Outcome Measure(s)

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Competitive employment (CE).

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28 Results

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Over the 24-month period, 92 of the entire sample of 213 IPS participants obtained

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competitive jobs for an overall employment rate of 43.2%. For the subsample of

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participants without TBI enrolled as outpatients (n=69), 36 obtained competitive jobs for

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an overall employment rate of 52.2%. Overall, employed participants averaged 38.2 ±

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29.7 weeks of employment, with an average time to first employment of 348.3 ± 220.0

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days. Nearly 25% of 1st jobs occurred within 4 to 6 months of beginning the program.

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Similar employment characteristics were observed in the subsample without TBI histories

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enrolled as outpatients.

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Conclusion(s)

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Almost half of the veterans with SCI participating in the 24-month IPS program as part of

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their ongoing SCI care achieved CE, consistent with their expressed preferences at the

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start of the study. Among a sub-sample of veterans without any TBI history enrolled as

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outpatients, employment rates exceeded 50%. Time to first employment was highly

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variable, but quite long in many instances. These findings support offering continued IPS

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services as part of ongoing SCI care to achieve positive employment outcomes.

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46 Key words: Employment, Supported; Spinal Cord Injuries; Veterans; Rehabilitation,

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Vocational

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List of Abbreviations

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CE

competitive employment

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CWT

Compensated Work Therapy

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IDT

Interdisciplinary Treatment Team

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IRB

Institutional Review Board

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IPS

Individual Placement and Support

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NEPEC

Northeast Program Evaluation Center

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RCT

Randomized Controlled Trial

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SE

Supported Employment

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SCI

Spinal Cord Injury

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SCI-VIP

Spinal Cord Injury Vocational Integration Program

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TBI

Traumatic Brain Injury

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US

United States

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VAMC

Veterans Affairs Medical Center

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VAP

Vocational Assessment Profile

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VHA

Veterans Health Administration

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VRS

Vocational Rehabilitation Specialist

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VR

Vocational Rehabilitation

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Since the early days of spinal cord injury (SCI) rehabilitation, employment has widely

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been accepted as a primary goal of rehabilitation.1 This perspective continues today as

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community reintegration has increasingly become a focus of rehabilitation.2,3 This

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emphasis is well justified, as employment is associated with improvements in health,

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well-being, quality of life, and social inclusion.4–6 Employment is associated with living

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not only a more satisfying life, but also a longer life. Over 40 years of longitudinal

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research have shown that longevity following SCI is strongly associated with

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employment.7 Not surprisingly, occupation is one of the highest priority needs expressed

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by persons with SCI.8 Despite this recognition, research on effective employment

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interventions for persons with SCI remains in the early stages of development. Expected

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employment outcomes from vocational treatment have not been established in the field,

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and the majority of persons with SCI do not return to employment following injury.9

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Cross-sectional research renders a wealth of information on predictors of employment

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following SCI,10–13 but prospective data on best practices for addressing vocational issues

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and establishing benchmarks for evaluating outcomes of traditional vocational

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rehabilitation (VR) programs and other approaches in SCI care are needed. Indeed,

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published reports on employment and SCI often cite employment rates without

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describing what vocational rehabilitation programs and which specific vocational

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services may have been received by the sample. 10-13 Hence, understanding the

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relationship between vocational interventions and expected employment outcomes is

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challenging. Moreover, there is virtually no published information comparing the

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effectiveness of different vocational interventions in SCI. Two recent systematic reviews

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determined that there is a profound lack of interventional studies on employment.14,15

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These reviews concluded that the strongest evidence for an effective vocational

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intervention in SCI was a single randomized controlled trial (RCT) of Individual

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Placement and Support (IPS) Supported Employment: the Spinal Cord Injury-Vocational

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Integration Program (SCI-VIP).16 This RCT achieved superior employment outcomes for

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IPS in SCI centers compared with the conventional practice of referring veterans with

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SCI to traditional VR outside the SCI center. Whether the employment outcomes seen in

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SCI-VIP represent what could be expected if IPS were a routine part of usual clinical care

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for SCI has yet to be determined.

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The intervention used in the SCI-VIP trial was the Individual Placement and Support

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(IPS) approach to Supported Employment (SE).17,18 Supported employment emerged in

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the 1980s as a vocational intervention to provide ongoing job supports to persons with

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psychiatric disabilities. Over the next two decades, IPS became the most studied and

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standardized approach of using SE to help persons with disabilities find competitive

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employment (CE) in their communities in line with consumer-driven preferences. IPS is a

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direct service with multiple components, including rapid job search, integration of

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rehabilitation services, job development, benefits counseling, and follow-along supports

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to sustain employment.19 Unlike more traditional models, which consist of pre-vocational

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activities or work readiness and which deliver vocational services by means of ad hoc

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referrals to external vocational rehabilitation agencies, the IPS model follows a “zero

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exclusion” principle, meaning that severity of disability is not a factor in eligibility and

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care is delivered using an integrated team-based model in which a vocational

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rehabilitation specialist (VRS) is a member of the health care team.

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116 The SCI-VIP study was the first test of an IPS-based SE program in a population of

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persons with a physical disability. In brief, SCI-VIP was a 5-year (2005-2010)

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randomized, controlled, multisite trial of IPS versus referral to traditional VR with 12

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months of follow-up, and the main outcome was CE of veterans with SCI.20 Results

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demonstrated that veterans with SCI randomized to 12 months of IPS were 2.5 times

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more likely to obtain CE than those in the traditional VR control condition and were 11.5

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times more likely to be employed than veterans followed at observational sites where IPS

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was not offered. Veterans who obtained employment had significantly greater social

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participation, home and community mobility, and time spent in productive roles.21 A

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subset of SCI-VIP study participants was then followed for up to 2 years, during which

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time employment data were collected and follow-along support was available on an “as

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needed” basis. The IPS employment rate remained significantly higher than the

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traditional VR in year 2.22 Those who received IPS also worked more hours and earned

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more wages than those who received traditional VR.

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Despite the positive outcomes in SCI-VIP, the mean employment rate of 25.9% for

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veterans with SCI who received a 12-month IPS program is less than the employment

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rates reported in studies of IPS for persons with serious mental illness. A recent

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systematic review reported a mean employment rate of 58.9% across 16 RCTs that were

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published between 1996-2012, with a mean follow-up of 18.8 months of IPS for serious

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mental illness.23 The medical complexity of the population in SCI-VIP, which included a

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significant proportion of co-morbid physical, cognitive, and/or psychiatric impairments

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likely contributed to employment outcomes being lower than those reported for persons

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with psychiatric disabilities, and we suspected that a longer IPS program may be needed

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to reach higher employment outcomes in this population. We believed that a higher

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employment rate would be observed with a longer implementation period that offered

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continuous availability of the full IPS intervention for persons with chronic SCI. The

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present paper describes the employment outcomes of a 24-month IPS program integrated

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with SCI clinical care in 7 SCI centers in the Veterans Health Administration (VHA) .

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146 147 Methods

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Subjects and settings

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The Predictive Outcome Model Over Time for Employment (PrOMOTE) was a

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longitudinal field study that extended the work of SCI-VIP, methods of which have been

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published previously.20 PrOMOTE was a 5-year (2010-2015) prospective, non-

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randomized, single-arm, multi-site project evaluating longitudinal employment, quality of

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life, and economic outcomes among a large cohort of veterans with SCI receiving

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medical and/or rehabilitation care from interdisciplinary care teams at 7 participating VA

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SCI centers located in geographically diverse sectors of the United States (3 of the 7

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PrOMOTE sites had also participated in SCI-VIP). The study had IRB approval at all

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sites. PrOMOTE consisted of two parallel studies: a large scale survey of health,

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employment, and quality of life among a representative sample of veterans with SCI and

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a longitudinal, observational study of a 24-month IPS program, which is the focus of the

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present report. The primary aims of the observational study were to determine the effect

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of IPS on employment rate, quality of life, and health care utilization. This paper reports

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on the employment outcomes.

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All veterans who met inclusion criteria were approached about completing a baseline

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interview to gather information on employment, health, and quality of life after SCI.

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Inclusion criteria for the baseline interview included: (1) between the ages of 18 and 65

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years old, (2) medically and neurologically stable, (3) enrolled in VHA, and (4) have a

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SCI. To be eligible to enroll in IPS, veterans had to meet the additional criteria of (1) not

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currently working in a paying job in the community, (2) express a desire for employment,

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and (3) live within 100 miles of the Veterans Affairs Medical Center (VAMC). Veterans

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with untreated psychosis, untreated alcohol or drug dependence, or a terminal illness

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were ineligible for IPS. Both inpatients and outpatients were eligible to enroll in IPS.

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Our broad inclusion criteria allowed for the enrollment of a heterogeneous sample, to

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reflect the common clinical characteristic of veterans with SCI who receive inpatient

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and/or outpatient treatment in the VHA SCI system of care throughout their lifespan. In

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this paper, we first report outcomes for the entire sample of participants with SCI, and

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then report outcomes for a subsample of participants with SCI and no TBI history that

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enrolled in the study and began IPS as outpatients. The latter description is provided as

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an illustrative example of the potential influence of treatment setting (and timing of

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intervention) and a common potentially influential co-morbidity (TBI) on outcomes.

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184 Of 279 veterans enrolled in IPS in PrOMOTE (Figure 1), 213 had no previous exposure

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to IPS through SCI-VIP while 66 had prior exposure to IPS because they served as study

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participants in SCI-VIP and were randomized either to IPS (n=30) or to traditional VR

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(n=36). Since SCI-VIP was not a blinded study, for purposes of the present study’s

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analysis of PrOMOTE employment outcomes, we conservatively included only those

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PrOMOTE study participants who had not served in the SCI-VIP trial (n=213).

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The 2-year rate of attrition was 21.6% (n=46), the majority of whom were lost during

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year 1 (71.7%, n=33). Reasons for attrition were: subject withdrawal (39.1%, n=18),

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death (19.6%, n=9), moved (13.0%, n=6), discharged or ineligible for VHA compensated

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work therapy (CWT) and/or SCI services (10.9%, n=5), incarcerated or facility safety and

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security restrictions (8.7%, n=3), terminal illness (2.2%, n=1), lost to follow-up (4.4%,

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n=2), and unknown (4.4%, n=2). An examination of demographic and clinical differences

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between subjects lost to follow-up and completing the study revealed no meaningful

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differences.

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Intervention

202 The intervention used in the PrOMOTE study was the IPS approach to SE used in the

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SCI-VIP RCT as described earlier. For a detailed description of the IPS SE intervention,

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readers are referred to the SCI-VIP methods paper.20 For a quick reference to how the

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foundational IPS principles24 were applied in the SCI centers, see Table 1.

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The IPS program was delivered by a VRS who received training both in IPS and in SCI

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specific medical management and rehabilitation. At each of the 7 participating SCI

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centers, the VRS was integrated as a provider into the SCI interdisciplinary care team.

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With the team’s support, the VRS provided a full continuum of IPS, which commonly

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included essential services such as vocational assessment and planning, job development,

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job placement, and follow-along support. A full list of services and their definitions are

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provided in the supplemental material. Throughout the study, implementation of IPS was

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supported by ongoing trainings, written manuals, and biannual fidelity monitoring (i.e.,

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audit and feedback on adherence to the IPS model). Also, a National IPS Clinical

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Coordinator provided ongoing technical assistance to all the VRSs.

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Outcomes

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The primary outcome was CE, meaning a job paying at least minimum wage in the

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community and available to any qualified person. Therefore, volunteer work and

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sheltered employment did not qualify as employment for this study. Secondary outcomes

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of interest were wages earned, hours worked, duration of employment, and other

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characteristics of employment (e.g., time to first job, job endings, job type). Duration of

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employment and wages earned over the 2 years were measured in weeks.

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Measures

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The following data were obtained through interviews and medical chart extraction: socio-

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demographics (self-reported race/ethnicity, sex, date of birth, and educational level), date

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of SCI, medical and psychiatric co-morbidities, financial information, and information on

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benefits received from the VHA and from Social Security. Employment history was

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categorized as follows: (a) employment at time of SCI and (b) employment within the

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immediate 5 years prior to study enrollment and (c) any employment post SCI. The Ohio

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State University Traumatic Brain Injury Identification Method (OSU-TBI-ID) was used

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to identify subjects with TBI.25 Participants were provided job journals to record their

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weekly employment activity (employment onset, duration, wages, and job

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classifications).This information was collected at quarterly interviews conducted by site

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research coordinators.

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The Individual Placement and Support (IPS) Fidelity Scale26 was used to measure

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adherence to the SE model. The Fidelity Scale consists of 15 items in three domains:

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staffing (3 items), organization (7 items), and services (5 items). Each item is rated on a

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scale of 1 to 5, higher numbers indicating better adherence to IPS (1 = poor, 2-3 = fair,

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4-5 = good). The total score for the scale is calculated by summing the item values

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(range: 15-75). A score > 65 is good IPS implementation; 56-65 is fair IPS

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implementation; and < 56 is not consistent with IPS. The published internal consistency

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coefficient for the instrument is .83, and subscale coefficients have ranged from .55 to

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.70.27 The Fidelity Scale was completed every 6 months by experts who conducted site

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visits and based ratings on interviews with staff, veterans, and employers and on medical

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chart reviews.

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Using results from the prior randomized trial,16 we calculated that 174 participants would

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be needed to demonstrate 80% power to detect an increase in employment rate from

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25.9% to 38.0% using a two-sided binomial test. These results assumed that the veteran

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SCI population employment rate under the null hypothesis was 25.9%. To account for

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expected attrition, we increased our sample size goal by 20% from 174 to 211.

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Statistical analysis

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Continuous parameters are reported as mean ± standard deviation (SD) and discrete

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parameters as percent (%). The primary outcome of interest was rate of competitive

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employment, presented as percent employed per group with 95% Wald confidence

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intervals (CI) with normal approximation. Employment rate was defined as the number of

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obtained jobs (1 per participant in the case of multiple employments) divided by the total

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number of participants. Secondary outcomes reported were wages earned, hours worked,

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duration of employment, and other employment characteristics (e.g., time to first job, job

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endings, job type). Missing data, approximately 1-2%, for medical and clinical data were

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minimized through the use of forced option data capture methods (i.e., item response

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selection during data entry is restricted to a predetermined range of responses) embedded

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within our electronic database. Missing data, approximately 5%, for vocational

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information collected regarding salary was excluded from analysis. No imputation was

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performed. For secondary outcomes, data were explored for departures from normality by

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standard descriptive statistics. Group comparisons were made with Student’s t-test or

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Wilcoxon rank sum tests with normal approximation, where appropriate, for continuous

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data and Pearson chi-square test, or Fisher’s Exact Test, where appropriate, for

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categorical data. All analyses were performed with SAS (Ver. 9.4, Cary, NC).

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Results

280 Subject characteristics

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Participant characteristics are presented in Table 2. Participants (n=213) were primarily

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male (96.7%), aged 51.0 ± 10.1 years (mean), and Caucasian (55.4%). At the time of

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study enrollment and baseline interview, 24.4% were hospital inpatients and 75.6% were

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outpatients. It should be noted that inpatient and outpatient status were not static

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conditions, as subsequent to enrollment participants may have experienced hospital

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discharges or admissions during the 24 month study period. Less than half of participants

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(47.9%) received any VHA benefits or service-connected benefits for SCI (22.5%). On

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average, participants received less than $1,000 per month ($946 ± $640) in non-service

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connected benefits, $837 ± $463 in Social Security Income (SSI), and $1,242 ± 460 in

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Social Security Disability Income (SSDI). At the baseline interview, most participants

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(63%) reported that they wanted to work part time, on average 26.9 hours per week.

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Medical and mental health characteristics

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Participant medical characteristics are presented in Table 3. Nearly half of participants

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reported cause of injury as either vehicular accident (29.1%) or fall (20.2%). When

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completeness and neurologic level of injury were combined to reflect varying impairment

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levels, 9.9% (n=21) of the sample had high tetraplegia with American Spinal Injury

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Association Impairment Scale (AIS) grade A, B, or C; 17.4% (n=37) had low tetraplegia

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with AIS grade A, B, or C; 27.2% (n=58) had paraplegia with AIS grade A, B, or C; and

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44.6% (n=95) had AIS grade D/E regardless of neurologic level. The majority of

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participants had bowel (72.3 %) or bladder (77.0%) impairments; many also had other

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medical conditions including spasticity (42.3%), hypertension (35.2%), pain (29.1%), and

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pressure ulcers (20.7%). More than half the sample (59.2%) had a lifetime history of

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traumatic brain injury as identified by the OSU-TBI-ID. Over one-third of the sample had

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depression (35.2%), and nearly 20% had substance abuse.

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Fidelity assessments

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Overall site fidelity scores were 65.0 ± 3.7 (range: 40-75), representing good

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implementation, with average scores across visits in the good range for 5 sites and the fair

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range for 2 sites.

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Employment rate, duration, wages and job classifications

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During the 24-month study follow-up period, 92 of 213 participants obtained competitive

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jobs for an overall employment rate of 43.2% (36.9%-50.2%) (Table 4). Twenty three of

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the 92 participants obtained more than one job during the study period. On average,

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subjects worked 15.1 ± 13.1 hours per week. While the majority (n =77, 83.6%) worked

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part time, 16.3% (n=15) achieved full time employment (greater than 32 hours per week). 15

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On average, subjects earned $265 ± $348 per week. Duration of employment averaged

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38.2 ± 29.7 weeks. The average time to first employment was 348.3 ± 220.0 days, and

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nearly 25% of first jobs were obtained within 4 to 6 months. Of the 115 jobs obtained, 52

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(45.2%) ended during the 2-year study. Of the 92 IPS participants who obtained jobs, for

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45 participants the job ended during the 24-month study follow-up period. Of these, 19

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subsequently worked 1 or more jobs while 26 obtained no further job during the study

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follow-up period. Of the 92 participants gaining employment, over half worked in

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management, business, science, and arts (36.6%) or sales and office (27.2%) jobs, while

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only a few participants (6.1%) worked in natural resources, construction, or maintenance.

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Subsample of participants without TBI enrolled as outpatients (n=69)

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Of IPS participants who were enrolled during outpatient care, 69 did not have any history

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of TBI (mild, moderate, or severe) on the OSU-TBI-ID. During the 24-month study

339

follow-up period, 36 of these 69 participants obtained 58 competitive jobs for an overall

340

employment rate of 52.2% (40.4%-63.8%). On average, subjects worked 15.4 ± 13.6

341

hours per week. While the majority (n=30, 83.4%) worked part time, 16.6% (n=6)

342

achieved full time employment (greater than 32 hours per week). On average, subjects

343

earned $244 ± $332 per week, or an annualized salary of $12,688 (range, $29-$85,228).

344

Duration of employment averaged 40.4 ± 31.7 weeks. The average time to first

345

employment was 312.5 ± 227.0 days, and nearly 47.4% of first jobs were obtained within

346

4 to 6 months. Of the 58 jobs obtained, 26 (44.8%) ended during the 2-year study. Of the

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36 IPS participants who obtained jobs, for 7 (19.4%), the job ended during the 24-month

348

study follow-up period. Of these, 1 subsequently worked 1 or more jobs while 6 obtained

349

no further job during the study follow-up period. Of the 36 participants gaining

350

employment, over half worked in management, business, science, and arts (44.7%) or

351

sales and office (23.7%) jobs, while only a few participants (7.9%) worked in natural

352

resources, construction, or maintenance.

353

Discussion

354

Veterans with SCI participating in a continuous 2-year program of IPS as part of their

355

SCI care achieved a competitive employment rate of 43.2%. The participants in this

356

program were a heterogeneous sample that reflected the medical complexity typically

357

seen in this population. Nearly 40% had a motor complete SCI (no movement or

358

sensation below the level of injury) and most of the sample also had a current or lifetime

359

history of co-occurring medical issues, mental illness, and/or brain injury. Services were

360

provided regardless of treatment setting, severity of disability, or chronic or acute

361

medical conditions experienced over the 2-year study period, such as pressure ulcers,

362

bowel or bladder problems, depression, or pain. Among those who were enrolled as

363

outpatients and had SCI with no reported history of TBI, the employment rate was even

364

higher, at 52.2%. Thus, a 24-month IPS program integrated into SCI care and following a

365

zero-exclusion principle, improved employment outcomes among veterans with

366

significant physical disability, high medical complexity, and co-occurring mental or

367

cognitive impairments.

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Although a higher employment rate was observed in a 24-month IPS program than the

369

rate obtained in the previous RCT of a 12-month IPS program in SCI, there are some key

370

differences between the two studies designs that make comparing the results challenging.

371

Given the well-known high rate of co-occurrence of SCI and TBI, we suspect that both

372

studies were clinically similar populations in terms of presence and severity of TBI.

373

However, the earlier study did not include a measure of TBI, whereas a strength of the

374

current study was the use of the OSU-TBI-ID to identify lifetime history of TBI.

375

Additionally, recruitment methods also differed between the studies. The earlier study

376

primarily recruited an outpatient sample of veterans with SCI. In the present study,

377

veterans were recruited without respect to inpatient or outpatient setting. While some

378

participants in both studies may have experienced hospitalization during IPS, a quarter of

379

the participants in the current study started IPS as inpatients, which would have put them

380

at a major disadvantage for rapidly engaging in job searches in the community. Indeed,

381

the current sample included a number of patients who had lengthy hospital stays during

382

the intervention period and may have been too medically compromised to fully

383

participate. In this respect, the 43.2% employment rate for our entire sample may be an

384

underestimate of results that could occur in outpatient SCI programs, particularly if they

385

screened for TBI. Therefore, the sample population and setting needs to be carefully

386

considered with respect to the study findings and generalizability.

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While the present study was not designed as a randomized comparison, its findings have

389

important implications. Although time of first job acquisition usually occurred early in

390

the program (months 4-6), new jobs were steadily acquired throughout the 24 months.

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This continuity of job acquisition highlights the need for ongoing rather than time-limited

392

services, and the importance of the full range of IPS services to support both job

393

acquisition and maintenance. At the time of enrollment, most participants expressed a

394

preference for part time work, and the outcome of most participants obtaining part time

395

work is consistent with the IPS consumer-driven approach. Rapid engagement, another

396

IPS practice principle, did not necessarily result in quickly obtaining employment, as

397

seen by the wide variability in time to employment in our sample. However, participants

398

were rapidly and directly engaged in active job seeking and job development with their

399

VRS and treatment team. This support eventually resulted in many becoming employed

400

in the community in their chosen field without the need for lengthy pre-vocational

401

assessments or activities such as work readiness or work hardening. Including follow-

402

along support as part of an ongoing IPS program enabled the VRS to work with the

403

individual, the employer, and the treatment team to make adjustments to support job

404

tenure such as adding or modifying work accommodations to improve performance,

405

changing bladder or bowel management routines to match work schedules, or adjusting

406

pain or spasticity medication management to avoid sedation on the job. Sometimes

407

during a period of follow-along support, the VRS may become aware that the individual

408

needs or desires a different position and initiate another phase of job development to find

409

work in a new setting. In the IPS model, follow along services allow VRSs to support job

410

transitions-- either in the case of advancing to a better paying or better fitting job based

411

on the participants’ preferences and career plans. The successful outcomes of IPS in the

412

present investigation are consistent with other studies showing active community-based

413

services such as job development, job placement, and follow-up support are associated

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with employment of persons with SCI.28,29 When providing these services, the knowledge

415

and expertise of the SCI clinical team is leveraged by the VRS while in the community

416

networking with employers and negotiating job placements based on the interests and

417

preferences of the individual with SCI. In previous work using IPS in SCI, time spent

418

providing these services in the community was more likely to result in competitive

419

employment outcomes than was traditional vocational counseling in office or clinic

420

settings.29

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Chronic unemployment may be associated with depression, low self-confidence, and

423

social disenfranchisement which present significant barriers to future employment.

424

Employment barriers are best addressed with a system that offers IPS services integrated

425

with medical care and that lasts throughout the working life of those who have been

426

unable to obtain and maintain work due to disability. According to existing data, a

427

minority of persons with SCI, about 35%,9,30 return to work. Even among veterans with

428

SCI who wanted employment, but received referrals to traditional VR, the average

429

employment rates in the SCI-VIP trial were remarkably low, ranging from 4.8% to

430

11.8%. In general, studies show that individuals with higher levels of education and those

431

who were employed before or at the time of injury are more likely to be employed.9,31 In

432

the current study sample, nearly half of the participants were employed prior to SCI,

433

only16.4% returned to work after SCI, and none were currently employed. Clearly, the

434

majority of persons with SCI most likely would benefit from more intensive and

435

coordinated supports to resume and sustain employment after injury. Although post-

436

injury education is a modifiable variable that could increase employment opportunities

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post-SCI,32 many persons with SCI are not inclined to go back to school and prefer

438

hands-on or action-oriented occupations.33,34 The rapid job search and job development

439

features of IPS are essential evidence-based vocational services for these persons, who

440

need help finding careers that align with their interests, goals, and current capabilities.

441

Unlike traditional VR models, which may require pre-vocational testing, training, or skill

442

building, the IPS model works with persons at their current level of functioning.

443

Moreover, based on a “recovery” model, IPS uses work as therapy--as a means to address

444

psychiatric and/or medical problems such as substance abuse, pain management, or

445

mobility as employment barriers--which motivates the patient to address the problems.

446

Instead of secondary conditions excluding or delaying vocational plans, the integration of

447

IPS with other rehabilitation interventions enables vocational goals to become part of a

448

holistic treatment plan to maximize health and independence. Continued follow-up

449

support by rehabilitation professionals is important, as recent evidence suggests that, as

450

persons adjust to SCI, their vocational interests may evolve and occupations that were not

451

considered initially may become viable options.35 In traditional VR models, referrals are

452

often made at the conclusion of rehabilitation to outside providers or agencies. This

453

approach may not support adapting vocational plans over time. Integrating IPS with

454

medical rehabilitation provides an opportunity to revisit vocational goals and make

455

adjustments as needed as individual age and/or as experience changes in their health or

456

lifestyle.

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The employment rate with 24 months of IPS in SCI approaches rates reported in a

459

number of RCTs of persons with serious mental illness treated in outpatient settings.23

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The mental health field has moved forward in establishing benchmarks for IPS success.

461

Using quarterly data from over 127 IPS mental health programs, standards have been set

462

for minimal (33%), moderate (45%) and high (57%) rates of employment success.36

463

While additional work on the adoption of IPS in standard SCI care is needed, the 24-

464

month results presented here may serve as a reference point for achievable employment

465

goals for IPS integrated into SCI care. In this study the subset of persons with SCI and no

466

TBI history who started IPS as outpatients achieved an employment rate over 50%, a rate

467

between the moderate to highly successful benchmarks of IPS success applied in

468

outpatient mental health settings. As a medically complex population, persons with SCI

469

likely face barriers not seen in the mental health population, such as neurogenic bowel

470

and bladder resulting in incontinence, risk for pressure ulcers, and neuropathic pain.

471

Developing disability-specific benchmarks or standards for vocational and therapeutic

472

care may be helpful to provide an appropriate treatment target for addressing vocational

473

goals as part of rehabilitation. Presently, there are no guidelines for how these issues

474

should be addressed following SCI, or expected outcomes of services for either the

475

rehabilitation program providers or consumers.

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From a rehabilitation perspective, employment should be addressed early in SCI

478

rehabilitation while there is still a close connection between the patient and the

479

interdisciplinary treatment team.37 On the other hand, referrals for IPS programs are

480

likely to be most beneficial at the time a person is able and willing to look for a job. From

481

a policy perspective, IPS is a resource-intensive service; hence, careful decisions need to

482

be made about who and when to refer to such a program. This study was conducted

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within the VHA, which is both federally funded and the largest integrated system of care

484

for SCI. In this setting, each VRS was a full-time employee of the local VAMC and

485

functioned as a member of the interdisciplinary rehabilitation team. For medically

486

complex rehabilitation populations such as SCI, comprising clients who are likely to

487

experience periodic health setbacks, the integrated team approach has clear advantages.

488

Most importantly, rapid access to the other team members can help address issues

489

quickly. State vocational rehabilitation programs, on the other hand, use a largely non-

490

integrated or partially integrated approach; VR providers may attend team meetings but

491

be employees of the state or private/for-profit VR providers. In other cases, they are

492

employed apart from medical centers. In the TBI literature, examples do exist in the

493

private sector of fee-for-service staff vendorized and embedded into academic medical

494

centers or clinic- based rehabilitation settings.38,39 While a cost-effectiveness analysis of

495

this 24-month IPS program is beyond the scope of this paper, the cost-effectiveness

496

analysis of the 12-month program demonstrated that the per patient cost to provide IPS

497

services in VA SCI centers has been low, at $1821 per patient.40 In the private sector,

498

higher program costs have been reported for persons with serious mental illness 41,42 or

499

traumatic brain injury.39 Depending on the setting and organizational context, IPS

500

program outcomes and costs are likely to vary and reimbursement sources and strategies

501

would be of importance. A pragmatic approach would be for inpatient rehabilitation

502

programs to treat employment as a viable goal and provide an orientation to IPS but

503

reserve initiation of full IPS program services until the time of hospital discharge when

504

persons can fully participate in community job development.

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24

Study limitations

507 Generalizability of this study may be limited due to the study population (veterans) and

509

setting (VA clinics) as well as self-reporting of data. The majority of participants were

510

male veterans, which may not reflect the general SCI population regarding potential for

511

employment. Our study population was recruited within proximity to large urban centers

512

for which transportation and employment opportunities may be easier than for persons

513

with SCI in more rural areas. The study did not directly measure level of veteran

514

participation in the IPS program; hence, the study cannot speak to the effects of treatment

515

adherence on outcomes. Care needs to be exercised in generalizing findings to other

516

populations, particularly in respect to treatment setting and inpatient versus outpatient

517

programs. Recognizing the heterogeneity of our entire sample, we reported findings for a

518

more homogeneous subgroup of persons without TBI who enrolled and began IPS as

519

outpatients as an example of outcomes that could be achieved with respect to presence of

520

one of the most common SCI comorbidities and the treatment setting at the start of IPS.

521

Although those participants who enrolled as outpatients were considered healthier at the

522

time of enrollment, members of this subgroup may have experienced a health change and

523

subsequent hospitalization during their study participation. Small sample size preludes

524

an analysis comparing those participants who remained exclusively inpatients vs

525

outpatients for the duration of the 24 month study. Additionally, by excluding those

526

with any reported history of TBI, this group excluded persons with mild TBI who likely

527

would have minimal or no residual cognitive impairment. This report should not be taken

528

to imply that SCI populations should be screened for TBI to determine eligibility, rather,

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the findings are reported to simply illustrate how additional comorbidities and timing of

530

treatment may impact the expected clinical outcomes. Furthermore, an analysis of other

531

variables (e.g., program fidelity and disability subsidies) that could have impacted

532

outcomes was beyond the scope of this report. Finally, these results are presented as a

533

descriptive report of employment outcomes during the 2 years that participants were

534

followed for data collection during the study funding period. Hence, the job tenure

535

observed in this time-limited study design does not provide an indication of the job

536

sustainability that may be seen in clinical practice where IPS is typically delivered as a

537

time-unlimited service based on each client’s needs.

538

Future directions

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Future research is needed to increase our understanding of how to efficiently and

541

effectively deliver employment interventions as part of medical rehabilitation for persons

542

with SCI in both the VHA and private sector. In particular, research designs with

543

adequate sample size are needed to examine the multiple factors that impact outcomes

544

including treatment setting, timing of intervention, and medical factors, as well as

545

program participation and fidelity. These types of studies would be helpful to establish

546

expected outcomes for IPS in SCI with respect to medical complexities seen in different

547

treatment settings. Furthermore, information is necessary to appreciate the impact of

548

including IPS in SCI on non-vocational outcomes and on health care utilization and to

549

identify effective strategies to integrate evidence-based supported employment services

550

into the SCI continuum of care.

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551 552 Conclusions

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A longitudinal examination of the use of IPS in SCI rehabilitation with a 24-month

556

implementation period showed positive employment outcomes among a sample veterans

557

receiving inpatient and/or outpatient care. For participants with no TBI history who

558

began IPS as outpatients, the employment rate was over 50%. Time to first employment

559

was highly variable. These findings support providing IPS services as part of SCI care to

560

improve employment outcomes and emphasize the need to provide continued services for

561

longer periods of time. The implementation of IPS in SCI and its expected outcomes need

562

to be considered with respect to the population served and the treatment setting.

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688

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687

EP

685

32

ACCEPTED MANUSCRIPT AMPR D-16-00556R2 / IPS in SCI

689

33

Figure Legends

690

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Figure 1. Study Participation Flow Diagram.

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691

33

ACCEPTED MANUSCRIPT IPS in SCI

Table 1. Application of IPS Principles to SCI IPS Principle

Application in SCI Center

Integrated treatment

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Vocational services are integrated with ongoing clinical care and management of SCI in the inpatient unit and outpatient clinics in the SCI Center.

Eligibility is based on the Veteran’s desire for work, not on severity of disability (e.g., all levels of SCI and neurological impairment are eligible for IPS).

SC

Zero exclusion

Veteran is engaged in active job search and job development activities in the community with the VRS, rather than pre-vocational

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Rapid engagement

assessment or work readiness activities. Competitive

The goal of the IPS program is competitive employment in the

employment

community rather than set-aside jobs for person with disabilities. Veteran preferences for work guide the job search, rather than

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availability of existing jobs. When existing jobs do not meet the

Client centered

Veteran’s preferences, job carving and job development is used to help the Veteran find the work they want. Services are delivered in the community rather than office or hospital settings. The VRS staff is expected to spend up to 70% of

EP

Community-based

their time out in the community working to assist with job finding

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and follow along support. Personalized benefits counseling is sought to help Veteran determine

Benefits counseling

the impact of future work on finances, and understand incentives and disincentives.* Follow-along support is provided by the VRS along with the SCI

Follow-along support

interdisciplinary team for as long as necessary to support job maintenance.

1 2

*VA benefits are protected while Veterans are participating in IPS SE through VA CWT.

ACCEPTED MANUSCRIPT AMPR D-16-00556R2 / IPS in SCI Table 2. Demographic Characteristics at Baseline Total

51.0 ± 10.1

Education, yr

13.9 ± 2.0

Male

206 (96.7)

Employed in ≤5 yr

45 (21.1)

Employed Pre-SCI

102 (47.9)

Employed Post-SCI

35 (16.4)

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SC

Age, yr

Race Caucasian

118 (55.4)

African American

83 (39.0) 4 (2.0)

Native American Other/Unknown

AC C

Divorced

EP

Marital Status

TE D

Asian

Married

RI PT

(N=213)

Other

1 (0.5) 7 (3.3)

70 (32.9) 72 (33.8) 71 (33.4)

Inpatient at Enrollment

52 (24.4)

VA Benefits

102 (47.9)

SC Benefits for SCI

48 (22.5)

If yes, SC 100%

44 (20.7)

1

ACCEPTED MANUSCRIPT AMPR D-16-00556R2 / IPS in SCI Table 2. Demographic Characteristics at Baseline Total

Non-SC Pension

20 (9.4)

Monthly Non-SC

$946 ± 640

SSI Amount, avg

$837 ± 463 $1,242 ± 460

SC

SSDI Amount, avg

RI PT

(N=213)

NOTE: Values expressed are mean ± SD or n (%). SCI, spinal cord

2

injury; SC, service connected; SSI, Social Security Income; SSDI,

3

Social Security Disability Income. ‘Employed ≤ 5 years’ refers to

4

any employment post-SCI but within 5 years of entry into the

5

study. ‘Employed Post-SCI’ refers to any employment post-SCI

6

but before entry into the study. Benefit amounts are in US dollars.

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7

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1

2

ACCEPTED MANUSCRIPT AMPR D-16-00556R1 / IPS in SCI

Table 3. Medical Characteristics of Participants of PrOMOTE (n=213)

Cause of Injury 62 (29.1)

Fall

43 (20.2)

Violence

18 (8.5)

Other/Unknown

90 (42.3)

SC

Vehicular accident

10.9 ± 11.1

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Avg. Time Since Injury, yr FIM Total

77.1 ± 25.7

ASIA Impairment Scale A

59 (27.7)

B

26 (12.2)

31 (14.6)

E

EP

AIS & Neurologic Level

TE D

C D

RI PT

Total (N=213)

93 (43.7) 2 (1.0)

21 (9.9)

Low Tetraplegia, AIS A,B,C

37 (17.4)

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High Tetraplegia, AIS A,B,C

Paraplegia, AIS A,B,C

58 (27.2)

AIS D/E

95 (44.6)

History of TBI on OSU-TBIID

126 (59.2)

Medical Comorbidities Neurogenic bladder

164 (77.0)

Neurogenic bowel

154 (72.3)

ACCEPTED MANUSCRIPT AMPR D-16-00556R1 / IPS in SCI

Table 3. Medical Characteristics of Participants of PrOMOTE (n=213)

173 (81.2)

Spasticity/Spasm of muscle

90 (42.3)

Hypertension

75 (35.2)

Pain

62(29.1)

Pressure ulcer

44 (20.7)

Arthritis

40 (18.8)

M AN U

SC

Other medical

RI PT

Total (N=213)

Urinary tract infection

36 (16.9)

Diabetes mellitus

31 (14.6)

Anemia

23 (10.8)

Autonomic dysreflexia

23 (10.8)

22 (10.3)

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Hepatitis Mental Health Comorbidities Dementia

Depression

EP

Schizophrenia

AC C

Bipolar disorder

Substance abuse

0 (0.0) 4 (1.9) 75 (35.2) 6 (2.8) 41 (19.2)

1

NOTE. Values expressed are mean ± SD or n (%). PrOMOTE, The Predictive Outcome Model Over Time

2

for Employment; FIM, functional independence measure; FIM, functional independence measure; ASIA,

3

American Spinal Injury Association; AIS, American Spinal Injury Association Impairment Scale; TBI,

4

traumatic brain injury; OSU-TBI ID, Ohio State University Traumatic Brain Injury Identification Method;

5

Pain (Low back pain, Central pain, Neuralgia, Shoulder pain); Arthritis (Spinal Canal Stenosis, Cervical

6

Spondylosis, Degenerative Joint Disease (DJD), Ankylosing Spondylitis, Rheumatoid Arthritis

ACCEPTED MANUSCRIPT AMPR D-16-00556R1 / IPS in SCI

Table 4. Employment Characteristics of Participants of PrOMOTE Obtaining Competitive Employment Total (n=92) 115

RI PT

Total number of obtained jobs Unique subjects obtaining a job, n (%)

92 (43.2)

Employment rate (95% CI)

43.2 (36.9-50.2)

Length of employment, weeks

38.2 ± 29.7

264.8 ± 348.2

SC

Wages per week, dollars Hours worked per week

15.2 ± 13.1

M AN U

Days worked per week SOC Classifications

2.6 ± 1.7

Management, Business, Science, & Arts

42 (36.6)

Sales and Office

31 (27.2)

Service

TE D

Production, Transportation, & Material Moving

Natural Resources, Construction, & Maintenance Hours missed per week Total number jobs left

18 (15.6) 16 (14.0) 7 (6.1) 1.1 ± 2.4 51 (44.3)

Quit

EP

Reason for job ending

17 (33.3) 6 (11.8)

Laid off

4 (7.8)

Fired

3 (5.9)

New job

2 (3.9)

AC C

Seasonal/contract completed

Other / Unknown Note. CI, confidence interval; SOC, Standard Occupational Classification

19 (37.3)

AC C

EP

TE D

M AN U

SC

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IPS SE Services – Brief Definitions

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● CWT Intake/Orientation—This process satisfies the requirement that any Veteran enrolled in IPS SE be enrolled in CWT and allows for monitoring by the Northeast Program Evaluation Center (NEPEC). ● Assertive Engagement & Outreach—These efforts convey the IPS SE model value that no one will be dropped from services due to missed appointments, unreturned calls, ambivalence, passive service refusal, or doubts about ability to work. ● Ongoing Vocational Assessment—The IPS model emphasizes the value of gathering assessment information even while a Veteran is working in a competitive job to ensure continuous updating of the Vocational Assessment Profile and vocational treatment plan. ● Focused Interview Assessment and Initial Vocational Assessment Profile (VAP)—This process is a critical part of ongoing vocational assessment, which allows the VRS to develop comprehensive knowledge about the Veteran via hands-on information gathering during several face-to-face meetings that focus on strengths, abilities, preferences for employment, and existing community contacts. ● Assistance in Obtaining Benefits Counseling—This SE principle ensures that Veterans enrolled in IPS SE receive accurate, comprehensive benefits counseling according to the type(s) of benefits they receive, which will help to address typical fears and concerns about the effects of returning to work on benefits eligibility. ● Treatment Plan Development—Following development of the VAP, the Veteran, the VRS, and the IDT develop a vocational treatment plan that addresses work goals, preferences, and supports and that outlines steps for goal attainment. ● Referral for Collateral Services—This is a treatment option when a needed resource has been identified but is not available within the VA and there is funding to offset costs. ● Network Contact—This is a contact made with or on behalf of a Veteran in the course of the job search with the objective of getting one step closer to a potential employer. ● Business and Industry Research—This research is conducted by the VRS in preparation for an employer contact and with the intention of gathering information that will help determine whether there is potential for a good job match. ● Job Development: Employer Contact—This occurs over several face-to-face meetings with a potential employer and has the ultimate objective of gathering enough information to determine whether a competitive job match might be made for a specific Veteran. ● Job Development: Employer Negotiations—These negotiations are held with a specific employer focused on hiring a specific Veteran and may be of the following types: Job proposal presentations, discussion of how the Veteran’s strengths fit the employer’s needs, job carving/creation, Veteran interviews, and schedule and shift determination. ● Vocational Rehabilitation Counseling—This process helps Veterans achieve their objectives through problem identification and resolution, examination of attitudes and feelings, consideration of alternative solutions, and decision-making. ● Worksite Accommodation—This is an individualized adjustment or alteration to a worksite or the way a job is performed to accommodate restrictions imposed by an injury or disability. Worksite accommodations must be negotiated with employers and are determined by a thorough job analysis. ● Vocational Case Management—Case management services provided by the VRS are those that are specifically related to the Veteran’s being equipped to participate in searching for, obtaining, and maintaining a competitive job. ● Employment Follow-Up/Follow-Along Supports—Based on an IPS principle, these are individualized, creative, and flexible supports intended to assist a Veteran in maintaining employment and are provided with any time limit. ● Treatment Plan Review/Revision—Review of each Veteran’s vocational treatment plan should occur at least monthly to allow for updates based on new profile information. Revision should occur at least every 3 months in concert with feedback from the IDT. ● Assistance with Job Transition—In the event that a Veteran’s job is no longer a good match, the VRS provides assistance in making the transition from one job to another, in framing the end of a job as a learning experience that will inform a new job search.

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● Consultation with CWT Staff-- Each VRS will attend weekly CWT/SE meetings and thereby participate as part of the vocational unit at the site as well as interact individually with colleagues and CWT Program Manager for additional assistance. ● Consultation with SCI IDT Member-Based on an IPS principle, the VRS will foster and facilitate integration of clinical and employment services by communicating regularly with SCI IDT members about Veterans with SCI who want to return to work or who are employed. ● Attending SCI IDT Meetings—In keeping with the IPS principle of treatment integration, the VRS attends weekly SCI IDT meetings to champion employment services as part of each Veteran’s treatment and to participate in shared decision-making with clinical colleagues.

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SC

This material is excerpted here from Ottomanelli L, Keleher V, Dirk L. IPS supported employment in SCI: implementation guide from the Predictive Model Over Time to Employment (PrOMOTE) Project. Appendix 5.1. 2016 October. Available at www.cindrr.research.va.gov/CINDRRRESEARCH/investigators_staff/lisa_ottomanelli.asp